Provider Demographics
NPI:1508491614
Name:JACKSON, JASON A
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19900 QUAIL HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-6364
Mailing Address - Country:US
Mailing Address - Phone:806-236-6974
Mailing Address - Fax:
Practice Address - Street 1:416 S TYLER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79101-2346
Practice Address - Country:US
Practice Address - Phone:806-322-5924
Practice Address - Fax:806-324-5511
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12239183500000X
TX37075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
175064OtherNABP